Carilion Clinic Medicare Health Plan: Are there any additional benefits? Additional coverage can improve your access to care

Silver (HMO-POS)

Plan Overview

Choose this plan if you want:

  • predictable, low co-pays and deductibles
  • no referrals for network providers
  • a choice in using network or out-of-network providers. If you use out-of-network providers, deductible and co-insurance apply.
  • $0 prescription deductibles

Medical Coverage Overview

Please refer to the Evidence of Coverage and Summary of Benefits for Out-Of-Network benefits.

  • Monthly Premium: $35 (You must continue to pay Medicare Part B premium)
  • Preventive care: $0
  • Visits to primary care physician: $10
  • Visist to chiropractors: $15 (Medicare-covered)
  • Visits to a specialist: $30
  • Maximum annual out-of-pocket for in-network medical services: $3,200 (excludes Part D prescription drugs)

Drug Coverage Overview

Costs below apply until yearly drug cost totals reach $2,930. These are the basic coverage rules. There are some exceptions, i.e. chemotherapy drugs.

Rx Category Up to 30-Day Supply Up to 90-Day Supply
Formulary Generics $5 Co-pay $15 Co-pay
Preferred Formulary Brands $35 Co-pay $105 Co-pay
Non-Preferred Generic and Non-Preferred Brand $65 Co-pay $195 Co-pay
Formulary Specialty Pharmaceuticals 33% 33%

More Information

The benefit information provided herein is a brief summary, not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. For full information on Carilion Clinic Medicare Health Plan benefits, call our Customer Service Department at 800-779-2285, TTY 877-225-3157, Monday through Friday, 8 am to 8 pm.

This is an advertisement; for more information contact the plan.

If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for it to take effect and you will remain responsible for those premiums.

You can also view additional plan documents in the Document and Forms section below.

Plan Specific Contact Information

Call us toll-free at: 877-233-7056, Monday through Friday, 8 am to 5 pm

Plan Disclaimers

Adobe Acrobat Document View Plan Disclaimers

Documents and Forms

The following documents provide detailed information on Carilion Clinic Medicare Health Plan (Silver HMO-POS) benefits and plan design. Use the links below to view Carilion Clinic Medicare Health Plan (Silver HMO-POS) documents directly from your computer.

If you would like any of these documents mailed to you, please Contact Us. You should receive the documents within two weeks of your request.


Adobe Acrobat Document Comprehensive Formulary - the open formulary for prescription drugs covered by Carilion Clinic Medicare Health Plan (Silver HMO-POS).

Adobe Acrobat Document Drugs That Require Prior Authorization - you will need authorization by your Carilion Clinic Medicare Health Plan (Silver HMO-POS Plan) before filling prescriptions for the drugs shown in this chart.

Adobe Acrobat Document Drugs That Require Step Therapy

Adobe Acrobat Document Drugs with Quantity Limits

Adobe Acrobat Document Evidence of Coverage with Annual Notice of Changes - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details.

Adobe Acrobat Document Low Income Subsidy (LIS) Premium Summary Table

Adobe Acrobat Document Medicare Part D Tiering or Formulary Exception Request

Adobe Acrobat Document Notice of Privacy Practices - describes how your medical information may be used and disclosed and how you can get access to this information.

Adobe Acrobat Document Provider Directory

Adobe Acrobat Document Summary of Benefits - provides a general summary of benefits and services for each of our health plans.

Adobe Acrobat Document Request for Appointment of Representative


[ Adobe Acrobat Document ] Adobe Reader required

Viewing these documents requires the Adobe Acrobat Reader, which can be downloaded for free by clicking here.

Click Here to download Adobe Reader